Local Anesthetics – Dosages and Toxicity

Local Anesthetics. Toxicity and Maximum Dosage

Local anesthesia is used to anesthetize areas in the body to perform surgical procedures, painful examinations or to only provide pain relief. Local anesthetic agents are divided pharmacologically into two groups; aminoamides and amino esters. Esters generally have higher toxicity than aminoamides (all amino esters have been deregistered in Sweden). The existing preparations in Sweden, all of which are of amide type, are:

  • Mepivacaine (Carbocaine®)
  • Lidocaine/lignocaine (Xylocaine®)
  • Prilocaine (Citanest®)
  • Ropivacaine (Naropin®)
  • Levobupivacaine (Chirocaine®)
  • Bupivacaine (Marcain®)

Chloroprocaine (Nesacaine®) is available in individual clinics as licensed agents. The preparations are available as solutions in different concentrations, usually half (5 mg/ml) or one-percent solution (10 mg/ml) with or without adrenaline additive. They also occur as spray, ointment, oral solution and in gel. Addition of adrenaline gives tolerance to higher maximum doses as the agents get slower spread in system circulation. Toxic reactions are usually due to overdose or rapid injection. Aminoamides metabolize in the liver and have a high degree of protein binding.

Overview of the most important local anaesthetics for peripheral nerve blocks

SubstanceConcentrationType of actionDosageTime until effectiveAnalgesic action time
Ropivacaine (Naropin®)0,5% - 0,75%AnaesthesiaUp to 300 mg10 - 20 min8 - 14 h
Ropivacaine (Naropin®)0,2% - 0,375%AnalgesiaUp to 28 mg/h10 - 20 min
Lidocaine (Xylocain®)1% - (2%)Up to 500 mg10 - 20 min2 - 4 h
Mepivacaine (Carbocain®)1% - (2%)Up to 300 mg10 - 20 min3 - 4 h
Anaesthetic potency
(ratio to procaine = 1)
Protein binding (%)Distribution volume (L)Elimination half-life (h) in plasma
Ropivacaine1694591.9
Lidocaine464911.6
Mepivacaine477.5841.9

Dosage in Different Regional Blocks

Infiltration Anaesthesia with Local Anaesthetic Agents

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 10 mg/ml1–20 ml 10–200 mg
Lidocaine (Xylocaine®) 10 mg/ml5-40 ml 50-400 mg
Levobupivacaine (Chirocaine®) 2,5–5 mg/ml1–20 ml 2,5–100 mg
Prilocaine (Citanest®)  5 mg/ml1-20 ml 5-100 mg

Nerve Block of Fingers and Toes

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml 2–4 ml 20–40 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml 20–50 mg
Mepivacaine (Carbocaine®) 20 mg/ml1-5 ml 20-100 mg
Prilocaine (Citanest®) 5 mg/ml1-5 ml 5-25 mg

Major Nerve Block

Axillary Plexus Block, TAP-block, Fascia Iliaca Compartment Block (FICB)
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-40 ml100-400 mg
Mepivacaine (Carbocaine®) 10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®) 20 mg/ml10–17,5 ml200–350 mg
Ropivacaine (Naropin®) *5 mg/ml10-40 ml75-300 mg
* Onset time 10-25 min, duration 6-10 h.

Medium Size Block

Supraclavicular Plexus Block, Infraclavicular Plexus Block, Interscalenius Block, Femoral Block, Sciatic Nerve Block, N. Saphenus Block, Ileoinguinal Nerve Block, Popliteal Block, PECS 2, M. Serratus Anterior Plane Block, Foot Block, Quadratus Lumborum Block
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml10-20 ml100-200 mg
Ropivacaine (Naropin®) *5 mg/ml1-30 ml5-150 mg
Ropivacaine (Naropin®) *7,5 mg/ml1-30 ml7,5-225 mg
Mepivacaine (Carbocaine®) 10 mg/ml10–20 ml100–200 mg
* Onset Time 1-15 min, duration 2-6 h.

Small Nerve Blocks

Block of Nervus medianus, n. ulnaris, n. radialis, n. cutaneus antebrachi lateralis, n. suprascapularis, n. lateralis cutaneus femoris, n. tibialis posterior, n. peroneus profundus and n. peroneus superficialis.
Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®) 10 mg/ml2-5 ml20-50 mg
Ropivacaine (Naropin®) *5 mg/ml2-5 ml10-25 mg
Mepivacaine (Carbocaine®) 10 mg/ml2–5 ml20–50 mg
* Onset Time 1-15 min, duration 2-6 h.

Epidural Anesthesia for Surgical Procedures

Local Anaesthetic AgentConcentrationBolus dose (ml)Bolus dose (mg)LA for continuous infusionBolus dose (mg)
Mepivacaine (Carbocaine®) 10 mg/ml10-20 ml100-200 mg
Mepivacaine (Carbocaine®) 20 mg/ml10-17.5 ml 200-350 mg
Bupivacaine (Marcaine®) 2.5 mg/ml 20 ml 50 mg followed by 6-16 ml/h15-40 mg *
Bupivacaine (Marcaine®) 5 mg/ml 15-30 ml75-150 mg
Bupivacaine (Marcaine®) 5 mg/ml20 ml followed by 50 mg followed by 2.5 mg/ml, 6-16 ml/h15-40 mg *
Levobupivacaine (Chirocaine®) 5.0-7.5 mg/ml10-20 ml 50-150 mg
Ropivacaine (Naropin®) 5-7.5 mg/ml 15-20 ml100-200 mg
Ropivacaine (Naropin®) 5 mg/ml 6-10 ml 6-10 ml/h30-50 mg *
* Every 4-6 hours alternatively in continuous infusion depending on the desired number of anethetized segments and the age of the patient

Epidural Block in Caesarian Sectio

Local Anaesthesia AgentConcentrationLoading VolumeLoading Dose
Levobupivacaine (Chirocaine®) 5 mg/ml*15–30 ml 75–150 mg
Mepivacaine (Carbocaine®)20 mg/ml 10–17,5 ml 200–350 mg
Bupivacaine (Marcaine®)5 mg/ml15–30 ml 75–150 mg
Chloroprocaine (Nesacaine®)30 mg/ml (3% )15–20 ml in bolus
Ropivacaine (Naropin®)5 mg/ml15-20 ml 113-150 mg
* By slow injection

Epidural for Obstetric Analgesia

Local Anaesthetic AgentConcentrationOpioidBolus doseContinuous infusion
Bupivacaine (Marcaine®) 2,5 mg/ml6-10 ml (15-25 mg)2-5 ml/h (5-12,5 mg/h)
Bupivacaine (Marcaine®)1 mg/ml plusSufentanil 1 microg/ml8-12 ml6-9 ml/h
Levobupivacaine (Chirocaine®) 2,5 mg/ml6-10 ml (15-25 mg)4-10 ml/h (5-12,5 mg/h) (1,25 mg/ml)
Ropivacaine (Naropin®) 2 mg/ml10-15 ml (20-30 mg),2-5 ml/hr (4-10 mg/hr)(2 mg/ml )
Ropivacaine (Naropin®) 1 mg/ml plusSufentanil 1 microg/ml12 ml6-9 ml/h
Standard mixture of local anesthetics plus opioid is usually given at a dose of 4-16 ml/h

Conversion of Epidural from Obstetric Analgesia into Caesarian Sectio ("Top-Up for C-Sec")

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)Opioid
Ropivacaine (Naropin®)5 mg/ml15-20 ml 113-150 mg+ Sufentanil 25 μg
Levobupivacaine (Chirocaine®) *5 mg/ml15–20 ml 75–100 mg
Bupivacaine (Marcaine®)5 mg/ml15–20 ml75–100 mg
Chloroprocaine (Nesacaine®)30 mg/ml (3% )15–20 ml
* Slow injection

Continous Epidural Anesthesia for Postoperative Analgesia

Local anestheticConcentrationOpioidAdditiveDosage
Bupivacaine (Marcaine®)1,0 mg/ml
(Breivik's blend, BFA)
Fentanyl 2 μg/mlAdrenaline 2 μg/ml8-14 ml/hour
Bupivacaine (Marcaine®)2,5 mg/mlSufentanil 0,5 μg/ml8-12 ml/hour
Bupivacaine (Marcaine®) 2,5 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Bupivacaine (Marcaine®)1,0 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)2 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)1 mg/mlSufentanil 0,5 μg/ml8-16 ml/hour
Ropivacaine (Naropin®)2 mg/mlSufentanil 1 ug/mlClonidine 3 ug/ml6-14 ml/hour
Ropivacaine (Naropin®)2 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/mlSufentanil 1 μg/ml8-16 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/mlMorphine Special 0,03 mg/ml5-10 ml/hour
Continous epidural anesthesia without opioids
Bupivacaine (Marcaine®)2,5 mg/ml5-7,5 ml/hour
Ropivacaine (Naropin®)2 mg/ml6-14 ml/hour
Levobupivacaine (Chirocaine®)1,25 mg/ml10-15 ml/hour
Levobupivacaine (Chirocaine®)2.5 mg/ml5-7,5 ml/hour
Standard blend of local anesthetics plus opioid is usually given at a dose of 4-16 ml/h

Spinal Anesthesia for General Surgery

Lower limb surgery including hip surgery

Local Anaesthetic AgentConcentrationDose (ml)Dose (mg)Onset TimeDuration
Bupivacaine (Marcaine Spinal®) 5 mg/ml2–4 ml 10–20 mg5–15 min2–4 hours
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml2–4 ml10–20 mg3–15 min1,5–3 hours
Ropivacaine (Naropin®)5 mg/ml3–4 ml15–20 mg1–5 min 2–6 hours
Levobupivacaine (Chirocaine®)5 mg/ml 3 ml15 mg
Urology surgery
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml 1,5–3 ml7,5–15 mg5–8 min1,5–3 hours
Abdominal Surgery
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml2–4 ml10–20 mg5–8 min45–60 min

Spinal Anaesthesia for Caesarian Sectio (C-Sec)

Local Anaesthetic AgentConcentrationDose (ml)Opioid
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8–2,4 ml (7,5–12,5 mg)
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μg
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Morphine 0,1 mg (0.4 mg/ml 0.25 ml)
Bupivacaine (Marcaine Spinal Heavy®)5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μgram + Morphine 0,1 mg (0,4 mg/ml 0,25 ml)
Ropivacaine (Naropin®)5 mg/ml1,5-3 ml (7,5-15 mg)
Spinal Anesthesia for pain during delivery final
Ropivacaine (Naropin®)5 mg/ml0,2-0,3 ml (1-1,25 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)
Bupivacaine (Marcaine Spinal®) 5 mg/ml0,2-0,4 ml (1-2 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)

Opiates as Adjuncts in Spinal Anesthesia

Local Anaesthetic AgentConcentrationDose in mgDose in ml
Morphine0.4 mg/ml0,1–0,2 mg0,25-0,5 ml
Fentanyl50 mikorg/ml20–40 μg0,4-0,8 ml
Sufentanil5 μg/ml5–10–(15) μg1-1,5 ml

Caudal Block for Surgical Anesthesia

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Lidocaine (Xylocaine®)10 mg/ml20–40 ml200–400 mg
Mepivacaine (Carbocaine®10 mg/ml15–20–30 ml150–200–300 mg
Mepivacaine (Carbocaine® 20 mg/mlup to 17.5 ml350 mg
Caudal Block in Small Children
Bupivacaine (Marcaine ®) 2,5 mg/ml
with epinephrine
0,5 ml/kg
Ropivacaine (Naropin®)2 mg/ml1 ml/kg

Intravenous Regional Anaesthesia IVRA Biers' Block

Target OrganLocal Anaesthetic AgentConcentrationVolume (ml)Dose (mg)
Mepivacaine (Carbocaine®) 0,5%5 mg/ml0,6 ml/kg3 mg/kg
Arm (Hand)Mepivacaine (Carbocaine®) 0,5%5 mg/ml20-60 ml100-300 mg
Arm (Hand)Lidocaine (Xylocaine®) 0,5%5 mg/ml20–40 ml100–200 mg
Leg (Foot)Lidocaine (Xylocaine®) 0,5%5 mg/ml40 ml200 mg
Arm (Hand)Prilocaine (Citanest®) 0,5%5 mg/ml 20-40 ml100-200 mg
Leg (Foot)Prilocaine (Citanest®) 0,5%5 mg/ml60-80 ml300-400 mg
Remark: intravenously, in a venous cannula on the dorsal side of the hand. Minimum dose: 35 ml. Maximum dose: 65 ml.


Local Anesthetics – Maximum Dose

Maximum Doses of Local Anesthetic Agents

 Mepivacaine (Carbocaine®)Lidocaine (Xylocaine®)Prilocaine (Citanest®)Ropivacaine (Naropin®)Levobupivacaine (Chirocaine®)Bupivacaine (Marcaine®)
Maximum dose singel blockade (4 hours)400 mg400 mg400 mg300 mg150 mg150 mg
Maximum dose mg/kg5 mg4 mg5 mg3 mg2 mg2 mg
Maximum daily dose1000 mg1200 mg1200 mg800 mg400 mg400 mg

A toxic reaction may occur unexpectedly and suddenly after an injection of local anesthetic agents with a dramatic influence on the patient’s condition, in pronounced cases the reaction can be life threatening. The reaction is usually due to overdose or rapid injection. In modern English-language literature, toxic reactions triggered by local anesthetics are called LAST (Local Anesthetic Systemic Toxicity). Dominant symptoms of a toxic reaction are CNS symptoms and cardiovascular symptoms, in severe cases with cardiovascular collapse. Usually, the reaction is short-lived and fast-moving but in pronounced cases the condition can quickly become life-threatening, especially severe symptoms are general seizures and bradycardia. Prior to major blockades (regional anesthesia), an intravenous peripheral venous catheter must always be present on the patient (PVC) in order to provide rapid intravenous treatment. Access to anesthesia equipment and possibilities for artificial respiration and life-saving efforts must also be available. The same applies always whenever more than 20 ml of local anesthetic is administered.

Toxic reactions are distinguished from allergic reactions, vasovagal reactions with fainting and side effects of adrenaline supplements. Vasovagal reactions with bradycardia and drop in blood pressure occur easily in painful injections – especially in young, nervous, irritated or slender individuals. Genuine allergic reaction to local anesthetic agents is extremely rare and is often confused with other unpleasant reactions, such as fainting, but allergic reaction to additives (carriers) in local anesthetic agents occurs sparsely. Referral to allergologists should be written in case of suspected true allergic reaction and a skin test should be performed under supervision. Carefulness with the term “Cave” shall apply to local anesthetics.

High concentrations of local anesthetic agents in the bloodstream may occur due to involuntary intravascular injection, overdose or unusually rapid absorption from rich vascularized tissues. Rapid absorption occurs during infiltration anesthesia, especially if the injection occurs in the face around the oral cavity, nose or throat. Central blockades (face, throat, scalp) cause greater risk of toxic reaction than peripheral blockades.

In epidural blockades, a toxic reaction occurs more easily if the injection occurs in a vein (epidural veins). The epidural is richly vascularized and an epidural catheter accidentally walks into or perforates a vein. If local anesthetic is given in an epidural vein, it circulates to the heart within one minute, which can cause a serious toxic reaction with sudden circulatory collaps. In the case of bloody aspiration in an epidural catheter, the catheter should be replaced. Injection of an epidural bolus dose (large dose) of local anesthetic should therefore always be preceded by an aspiration test for blood and administration of a test dose, which may detect excessive uptake in system circulation. Addition of adrenaline in the test dose may facilitate the detection of an intravenous injection by responding to the patient with rapid heart rate (tachycardia). Toxic reactions are due to high plasma concentrations, usually short term. Adrenaline administration in local anesthetic agents causes local vasoconstriction, which inhibits absorption and reduces the risk of systemic toxicity in the well-established epidural. As a rule, therefore, higher doses of local anesthetic agents with adrenaline are tolerated than without.


Local Anesthesia – Toxic Reaction and Treatment

A toxic reaction may occur unexpectedly and suddenly after an injection of local anesthetic agents with a dramatic influence on the patient’s condition, in pronounced cases the reaction can be life threatening. The reaction is usually due to overdose or rapid injection. In modern English-language literature, toxic reactions triggered by local anesthetic systemic toxicity (local anesthetic) are called LAST. Dominant symptoms of a toxic reaction are CNS symptoms and cardiovascular symptoms, in particular cases of cardiovascular collapse. Usually, the reaction is short-lived and fast-moving but in pronounced cases the condition can quickly become life-threatening, especially severe symptoms are general seizures and bradycardia.

Prior to major blockades (regional anesthesia), an intravenous peripheral venous canal must always be present on the patient (PVK) in order to provide intravenous treatment. Access to anesthesia equipment and possibilities for artificial respiration and life-saving efforts must also be available. The same applies always when more than 20 ml of local anesthetic is administered. The risk of a toxic reaction becomes particularly high if bolus doses are given on top of a continuous infusion that goes into an infusion pump. Particularly sensitive is the continuous infusion of bupivacaine (Marcain®) which has a relatively long half-life. Extra bolus doses for a patient who is continuously injecting bupivacaine must be administered with extreme caution and preferably with other drugs with lower toxicity, such as lidocaine or mepivacaine. The toxicity of different local anesthetics given simultaneously is additive.

Symptoms of toxic reaction

  • Slow slurred speech (dysartria)
  • Lightheadedness
  • Circumoral paresthesia
  • Numbness in the tongue
  • Hyperacusia, tinnitus
  • Visual disturbances
  • Tics
  • Tremor
  • Generalized seizures
  • Unconsciousness
  • Bradycardia
  • Asystole

Treatment of toxic reaction

  • Immediately discontinue the supply of local anesthetic agents
  • Put the patient down in the backrest position with a slightly raised head end
  • Oxygen via breathing mask (always!)
  • Careful monitoring of alertness and breathing
  • Support breathing and circulation, avoid hypoxia and carbon retentionIf required: controlled manual ventilation, mask ventilation or intubation
  • If seizures do not stop spontaneously within 15-20 seconds, Tiopenthone (Pentocur) is given 1-3 mg/kg i.v. (50-100 mg) or diazepam 0.1 mg/kg i.v. (5-10 mg, seems slightly slower). Alternatively to Tiopenthone, propofol is given 10-60 mg slowly i.v.
  • Injection of muscle relaxants, e.g. suxametonium 1 mg/kg, creates more favorable conditions for manual ventilation and oxygenation of the patient
  • In the case of hypotension/bradycardia, a vasopressor is given, e.g. ephedrine 5-10 mg i.v. (may be repeated after 2-3 minutes) or adrenaline 0.05-0.1 mg i.v. (repeated doses 0.1 mg/ml)
  • Atropine 0.5-1 mg i.v. should be given at bradycardia. Give repeated doses
  • Sodium bicarbonate (50-100 ml, 60-120 mmol) at acidos on liberal indication
  • Hypertonic saline solution is given in broad-scale QRS complexes (200 mmol sodium is administered rapidly i.v.)
  • Lipid treatment (ILE) should be initiated in cardiovascular collaps

Lipid treatment (ILE)

In case of circulatory arrest, cardiac resuscitation should be performed immediately and lipid emulsion therapy (ILE) should be tested.

Give a bolus of a 20% lipid emulsion (Intralipid®) 1 ml/kg i.v. altogether 100-200 ml fast intravenously. Start an infusion with the same lipid emulsion 0.25 ml/kg/min for 10 minutes, as long as cardio pulmonary resuscitation (CPR) is performed, alternatively another 100 ml is given intravenously. Bolus doses can be repeated every 5 minutes, two or three times if necessary, 1 ml/kg. More than 8 ml/kg of lipid emulsion should not be given.

Blood sampling: Arterial blood gas with acid base status, frequent electrolyte controls (routine status), β-glucose. Continued treatment is based upon the patient’s condition. Long-term cardiovascular rescue may be required in toxic reaction of bupivacaine (Marcain®) with high toxicity and high apparent volume of distribution (Vd).


Mepivacaine (Carbocain®)

Mepivacaine (Carbocain®) is used for infiltration anesthesia, intravenous regional anesthesia (IVRA), peripheral and regional blocks. Mepivacaine has fast onset and low acute toxicity. Effectiveness comparable to lidocaine, but less toxic and slightly longer duration.

Concentration:

Injection solution 10 mg/ml, 20 mg/ml, (30 mg/ml for dental use). Injection solution 10 mg/ml + adrenaline 5 μg/ml, 20 mg/ml + adrenaline 5 μg/ml.

Dosage:

Maximum dose is 5 mg/kg, single-dose 400 mg = 40 ml, 10 mg/ml (80 kg patient weight). Maximum daily dose 1000 mg.

Half-life (t1/2 1.9 h)

Maximum dose is 5 mg/kg and body weight at 70 kg provides a dose of 350 mg, 10 mg/ml = 35 ml, with adrenaline 7 mg/kg = 490 mg = 49 ml. At a concentration of 20 mg/ml maximum volume is 17,5 ml). At body weight 70 kg maximum dose is 350 mg/4 h.

Intravenous Regional Block (IVRA – Biers Block)

Mepivacaine (Carbocain®) 5 mg/ml, dose: 3 mg/kg = 0.6 ml/kg body weight intravenously, in venous cannula on dorsal side of hand. Minimum dose: 35 ml. Maximum dose: 65 ml.

Nerve block on fingers and toes

  • Mepivacaine (Carbocain®) 10 mg/ml, 2-5 ml (20-50 mg)
  • Mepivacaine (Carbocain® 20 mg/ml, up to 5 ml (100 mg)

Caudal Surgical Anesthesia

  • Mepivacaine (Carbocain®) 10 mg/ml, 15-20-30 ml (150-200-300 mg)
  • Mepivacaine (Carbocain®) 20 mg/ml up to 17.5 ml (350 mg)

Infiltration Anesthesia

  • Mepivacaine (Carbocain®) 10 mg/ml, 1-20 ml (10-200 mg)

Regional Blocks

  • Major blocks: Mepivacaine (Carbocain®) 20 mg/ml, 10-17.5 ml (200-350 mg mepivacaine)
  • Small to medium blockades: Mepivacaine (Carbocain®) 10 mg/ml, 10-20 ml (100-200 mg mepivacaine)
  • Fingers and toes: Mepivacaine (Carbocain®) 10 mg/ml, 1-5 ml (10-50 mg).

Epidural Anesthesia

  • Mepivacaine (Carbocain®) 10 mg/ml, 10-20 ml (100-200 mg)
  • Mepivacaine (Carbocain®) 20 mg/ml, 10-17.5 ml (200-350 mg)

Levobupivacaine (Chirocaine®)

Levobupivacaine (Chirocaine®) is used for infiltration anesthesia, for peripheral and regional blocks, as well as for epidural anesthesia and spinal anesthesia. It is not used for blocks on toddlers.

Concentration:

Injection solution 2.5 mg/ml, 5 mg/ml, 7.5 mg/ml. Infusion fluid 0.625 mg/ml, 1.25 mg/ml. The infusion fluid is mainly used for continuous epidural infusion.

Levobupivacaine has intermediate toxicity.

Dose:

Maximum dose is 2 mg/kg without adrenaline, 3 mg/kg with adrenaline, Maximum dose in single-dose is 150 mg (over 4 hours). Maximum daily dose 400 mg (over 24 hours). Maximum dose at 70 kg body weight: at concentration 2.5 mg/ml 60 ml, at concentration 5 mg/ml 30 ml in one single block.

T half-life (t1/2): 1.3 h

Dosage:

Infiltration anesthesia

  • Levobupivacaine (Chirocaine®) 2,5–5 mg/ml, 1–20 ml (2,5–100 mg)

Epidural Anesthesia

  •  Levobupivacaine (Chirocaine®) 5.0/7.5 mg/ml, bolus in surgery (slow), adults 10-20 ml (50-150 mg)

Epidural Anesthesia in Caesarian Sectio

  • Levobupivacaine (Chirocaine®) slow injection, 15-30 ml (75-150 mg), 5.0 mg/ml

Epidural Anesthesia in Obstetric Analgesia

  • Levobupivacaine (Chirocaine®) 2.5 mg/ml, bolus 6-10 ml (15-25 mg) plus continuous infusion 1.25 mg/ml, 4-10 ml/hr (5-12.5 mg/hr)

Epidural anesthesia for Postoperative Analgesia 

  • Levobupivacaine (Chirocaine®) 1.25 mg/ml, 10-15 ml/hr (12.5-18.75 mg/hr)
  • Levobupivacaine (Chirocaine®) 2.5 mg/ml, 5-7.5 ml/hr (12.5-18.75 mg/hr)

Spinal Anesthesia 

  • Levobupivacaine (Chirocaine®) 5 mg/ml. Lower limb block including hip surgery. Dose: 3 ml, 15 mg.

Opiates used in spinal anesthesia

  • Morphine 0.1-0.3 mg (0.4 mg/ml)
  • Fentanyl 20-40 μg (50 μg/ml)
  • Sufentanil 5-10- (15) μg (5 μg/ml)

Prilocaine (Citanest®)

Prilocaine (Citanest®) is used for infiltration anesthesia, for peripheral and regional blockades. It is also used as oral anesthetics by dentists.

Concentration

Injection solution 5 mg/ml. Injection dental solution, 30 mg/ml + Octapressin 0.54 μg/ml.

Dose

Maximum dose: Prilocaine (Citanest®) has low toxicity.  5 mg/kg, maximum dose single-dose 400 mg (80 ml). Maximum dose with adrenaline 8 mg/kg. Maximum daily dose is 1200 mg.

Half-life (t1/2) 1.6 h

Dosage

Infiltration anesthesia

  • Prilocaine (Citanest®) 5 mg/ml, 1-20 ml (5-100 mg)

Intravenous Regional Anesthesia (IVRA – Biers Block)

  • Arm: Prilocaine (Citanest®) 5 mg/ml, 20-40 ml (100-200 mg)
  • Leg: Prilocaine (Citanest®) 5 mg/ml, 60-80 ml (300-400 mg)

Bupivacaine (Marcaine®)

Bupivacaine (Marcaine®is used for infiltration anesthesia, for regional anesthesia, epidural anesthesia and spinal anesthesia. Bupivacaine (Marcaine®) should not be used for IVRA (Bier blockade). Bupivacaine has high toxicity.

Concentration

Injection solution 2.5 mg/ml, 5 mg/ml. Injection solution 2.5 mg/ml + adrenaline 5 μg/ml, 5 mg/ml + adrenaline 5 μg/ml. Bupivacaine (Marcaine Spinal®) 5 mg/ml. Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml.

Dosage

Maximum dose is 2 mg/kg without adrenaline, 2-3 mg/kg with adrenaline. Maximum dose once-only 150 mg within 4 hours. Give 5 mg/ml not more than 30 ml, 2.5 mg/ml not more than 60 ml.

Maximum daily dose is 400 mg. (max 2.0 mg/kg at 70 kg yields 140 mg, 5 mg/ml = 28 ml, with 3 mg/kg = 210 mg yield not more than 42 ml). Maximum volume at 70 kg body weight: at concentration 2.5 mg/ml – 60 ml, at concentration 5 mg/ml – 30 ml.

Half-life (t1/2) 2.7 h

Caudal Block

  • Caudal block in small children: Bupivacaine (Marcaine®) 2.5 mg/ml with adrenaline, give 0.5 ml/kg.

Epidural Anesthesia

  • Bupivacaine (Marcaine®) 5 mg/ml, 20 ml (50 mg) followed by 2.5 mg/ml 6-16 ml (15-40 mg) every 4-6 hours depending on the desired number of anesthetized segments and the age of the patient
  • Bupivacaine (Marcaine®) 5 mg/ml, 15-30 ml (75-150 mg)

Epidural in Caesarian Sectio

  • Bupivacaine (Marcaine®) 5 mg/ml, 15-30 ml (75-150 mg)

Epidural Anesthesia in Obstetric Analgesia

  • Bupivacaine (Marcaine®) 2.5 mg/ml, bolus 6-10 ml (15-25 mg) plus continuous infusion 2.5 mg/ml 2-5 ml/t (5-12.5 mg/h)
  • Bupivacaine (Marcaine®) 1 mg/ml + Sufenta 1 μg/ml, bolus 12 ml plus continuous infusion 9 ml/h

 Epidural Anesthesia for Postoperative Pain Treatment

  • Bupivacaine (Marcaine®) 5 mg/ml, bolus 5-10 ml, 12.5-25 mg
  • Continuous infusion: Bupivacaine (Marcaine®) 5 mg/ml 5-7.5 ml/h 12.5-18.75 mg.

Spinal Anesthesia

Lower limb orthopedic surgery including hip surgery:

  • Bupivacaine (Marcaine Spinal®) 5 mg/ml. Dose: 2-4 ml, 10-20 mg. Onset time 5-8 min. Duration 1.5-4 hours.
  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml. Dose: 2-4 ml, 10-20 mg. Onset time 5-8 min. Duration 1.5-4 hours.

Urological surgery:

  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml. Dose: 1.5-3 ml, 7.5-15 mg. Onset time 5-8 min. Duration 2-3 hours.

Abdominal surgery:

  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml. Dose: 2-4 ml, 10-20 mg. Onset time 5-8 min, duration 45-60 min.

Caesarian Sectio:

  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml, volume 1.5-3 ml, dose: 7.5-15 mg. Onset time 5-8 min, duration 45-60 min
  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml, Dose: 1.5-2.2 ml + Fentanyl 10-25 μg + Morfin 0.1-0.125 mg (0.4 mg/ml 0.25-0.3 ml)
  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml, Dose: 1.5-2.2 ml + Fentanyl 10-25 μg
  • Bupivacaine (Marcaine Spinal Heavy®) 5 mg/ml, Dose: 1.5-2.2 ml + Morphine 0.1-0.125 mg (0.4 mg/ml 0.25-0.3 ml)

Opioids in Spinal Anesthesia

  • Morphine 0.1-0.3 mg (0.4 mg/ml)
  • Fentanyl 20-40 μg (50 μg/ml)
  • Sufentanil 5-10- (15) μg (5 μg/ml)

Ropivacaine (Naropin®, Narop®)

Ropivacaine (Naropin®) is used for infiltration anesthesia, for peripheral and regional anesthesia blocks, for epidural anesthesia and spinal anesthesia. Ropivacaine is also used for caudal blocks on children. Favourable effective dose/ toxicity ratio. Good differential block (analgesia >> motor block) at lower concentrations for analgesia.

Concentration

Injection solution at 2 mg/ml, 5 mg/ml, 7.5 mg/ml, 10 mg/ml. Ropivacaine is not available with adrenaline additive.

Dosage

Ropivacaine (Naropin®) has intermediate toxicity.

Maximum dose is 3 mg/kg, Maximum dose at single dose 300 mg. Daily dose 800 mg (3 mg/kg). At weight 70 kg give no more than 210 mg.

If the solution of 2 mg/ml is used give Maximum 100 ml at weight 70 kg, if concentration of 5 mg/ml is used give maximum 40 ml, if concentration 7.5 mg/ml maximum 26 ml, if concentration 10 mg/ml give no more than 20 ml.

Half-life (t 1/2 h) 1.8 h

Small to medium size peripheral blockade

  • Ropivacaine (Naropin®) 5 mg/ml, 1-30 ml, 7.5-225 mg. Onset time 1-15 min, 2-6 h.

Caudal Block 

  •  In small children: Ropivacaine (Naropin®) 2 mg/ml, 1 ml/kg.

Brachial Plexus Block

  • Ropivacaine (Naropin®) 5 mg/ml, 10-40 ml, 75-300 mg. Onset time 10-25 min, duration 6-10 h.

Epidural Anesthesia

  • Ropivacaine (Naropin®) 5-7.5 mg/ml 15-20 ml (100-200 mg ropivacaine) then
  • Ropivacaine (Naropin®) 5 mg/ml 6-10 ml (30-50 mg ropivacaine) every 4-6 hours alternatively in continuous infusion depending on the desired number of anethetized segments and the age of the patient

Epidural Anesthesia for Postoperative Pain Treatment

  • Ropivacaine (Naropin®) 2 mg/ml, 6-14 ml/hr, 12-28 mg/hr.

Epidural Anesthesia in Caesarian Sectio

  • Ropivacaine (Naropin®) 5 mg/ml, 15-20 ml (113-150 mg)

 Epidural Anesthesia in Obstetric Analgesia

  • Ropivacaine (Naropin®) 2 mg/ml, bolus 10-15 ml (20-30 mg) plus continuous infusion 2 mg/ml 2-5 ml/hr (4-10 mg/hr)
  • Ropivacaine (Naropin®) 1 mg/ml + Sufenta 1 μg/ml, bolus 12 ml plus continuous infusion 6-9 ml/h

 

Spinal Anesthesia 

Lower limb operations including hip surgery

  • Ropivacaine (Naropin®) 5 mg/ml. Dose: 3-4 ml, 15-20 mg. Onset Time 1-5 min. Duration 2-6 hours.

Urological surgery

  • Ropivacaine (Naropin®) 5 mg/ml. Dose: 1.5-3 ml, 7.5-15 mg. Onset Time1-5 min. Duration 2-6 hours.

Abdominal surgery

  • Ropivacaine (Naropin®) 5 mg/ml. Dose: 2-4 ml, 10-20 mg

Spinal Anesthesia in Caesarian Sectio

 Ropivacaine (Naropin®) 5 mg/ml: Dose: 1.5-3 ml, 7.5-15 mg. Onset time 1-5 min. Duration 2-6 hours.

Combination Spinal with opioids

  • Morphine 0.1-0.3 mg (0.4 mg/ml)
  • Fentanyl 20-40 μg (50 μg/ml)
  • Sufentanil 5-10- (15) μg (5 μg/ml)

Lidocaine (Xylocaine®, Lidocaine®, Lignocaine®)

Lidocaine (Xylocaine®) is used for infiltration anesthesia, for peripheral and regional anesthesia blockades. Also used for topical anaesthesia for skin and mucous membranes. Local anaesthetic with medium action time and low toxicity.

Concentration

Injection solution 10 mg/ml, 20 mg/ml, (30 mg/ml for dental use).Injection solution 10 mg/ml + adrenaline 5 μg/ml, 20 mg/ml + adrenaline 5 μg/ml. Dental injection solution, 20 mg/ml + adrenaline 12.5 μg/ml. Spray 10 mg/dose. Ointment 5%. Gel 2%. Oral solution 2%.

Dosage

Lidocaine (Xylocaine®) has low toxicity.

Maximum dose is 4 mg/kg without adrenaline, 7 mg/kg with adrenaline.

Single block maximum dose is 400 mg (4 mg/kg at weight 70 kg 280 mg, with adrenaline 7 mg/kg 490 mg). Spray Xylocaine (10 mg/dose) give up to 10 spray doses. Maximum day and night dose is 1200 mg.

Half-life (t 1/2) 1.6 h.

Infiltration Anesthesia 

  • Lidocaine (Xylocaine®) 10 mg/ml, 5-40 ml (50-400 mg).

Regional Anesthesia

Large blocks:

  • Lidocaine (Xylocaine®) 20 mg/ml, 10-17.5 ml (200-350 mg)

Small to medium blockades:

  • Lidocaine (Xylocaine®) 10 mg/ml, 10-20 ml (100-200 mg)

Fingers and toes:

  • Lidocaine (Xylocaine®) 10 mg/ml, 1-5 ml (10-50 mg).

Intravenous Regional Anesthesia (IVRA – Biers Block)

  • Arm: Lidocaine (Xylocaine®) 5 mg/ml, 20-40 ml (100-200 mg)
  • Leg: Lidocaine (Xylocaine®) 5 mg/ml, 40 ml (200 mg)

Nerve block on fingers and toes

  • Lidocaine (Xylocaine®) 10 mg/ml, 2-4 ml (20-40 mg)

Sacral surgical analgesia

  • Lidocaine (Xylocaine®) 10 mg/ml, 40 ml (400 mg)

Sacral obstetric analgesia

  • Lidocaine (Xylocaine®) 10 mg/ml, 20-30 ml (200-300 mg)